Current professional practice in Brazilian mental healthcare services
Prácticas profesionales en servicios de salud mental
Praticas profissionais nos serviços de saúde mental
Antonia R. Ferreira-Furegato, Sueli A. Frari-Galera, Sandra C. Pillon and Lucilene Cardoso
Received 23th May 2011/Sent for Modification 27th February 2012/Accepted 24th May 2012
Objective Mental health reform in Brazil presupposes mental health becoming integrated into the Brazilian health system, involving multidisciplinary teams whose professional practice has yet to be defined. The present study forms part of a project aimed at understanding human resources practices in Brazilian mental healthcare services.
Methods This was a descriptive, exploratory study using a sample of highly qualified practitioners involved in the Ribeirao Preto/SP public mental health network. The project was approved by the Ribeirao Preto College of Nursing/University of Sao Paulo's ethics committee. A semi-structured questionnaire was used and the data was statistically analyzed.
Results One hundred and forty-four of the 193 practitioners from the 8public mental and psychiatric health care services agreed to participate. It was observed that current practice was mainly based on individual care, emphasizing medical, psychological and nursing care. Group activities were more frequently provided by community services.
Conclusion Mental care was infrequently prescribed and a low value was placed on activities like observation, recording and therapeutic interaction. Mental care services were being structured; however, practitioners still had difficulties in implementing current policy.
Key Words: Mental health service, human resources, nurse-patient relationships, medical assistance (source: MeSH, NLM).
Objetive La aplicación de la reforma de la salud mental en Brasil, supone la integración de la salud mental en el Sistema Nacional de Salud con los equipos multidisciplinarios cuyas prácticas se están definiendo. Esta investigación es parte de un proyecto que intenta comprender las prácticas de recursos humanos en servicios de salud mental.
Método Se realizó un estudio descriptivo exploratorio con una muestra compuesta por profesionales de alto nivel de la red pública de salud mental, en Ribeirão Preto/SP. Proyecto aprobado por el Comité de Ética. Se utilizó un cuestionario estructurado y los datos fueron analizados estadísticamente.
Resultados Un total de 144 de 193 profesionales de ocho servicios públicos de salud mental aceptaron participar. Se observó que las prácticas se basan principalmente en la asistencia individual, con énfasis en la atención médica, psicológica y de enfermería. Las actividades en grupo son más frecuentes en el servicio comunitario.
Conclusión Hay muy poco valor de la prescripción y bajo valor para actividades como la observación, el registro y la interacción terapéutica. Se concluye que los servicios se están estructurando; sin embargo, los profesionales siguen teniendo dificultades para la implementación de las políticas.
Palabras Clave: Servicios de salud mental, recursos humanos; relaciones enfermero-paciente; Asistencia médica (fuente: DeCS, BIREME).
Objetivo A implementação da reforma psiquiátrica no Brasil, pressupõe integração da saúde mental no Sistema Único de Saúde com equipes multiprofissionais cujas práticas ainda estão sendo definidas. A presente pesquisa é parte de um projeto que tem por objetivo conhecer a organização e as práticas dos recursos humanos em serviços de saúde mental.
Método Trata-se de um estudo exploratório descritivo, com amostra composta pelos profissionais de nível superior da rede pública de saúde mental, do município de Ribeirão Preto/SP. Projeto aprovado por Comitê de Ética. Utilizou-se um questionário semi estruturado cujos dados foram estatisticamente analisados.
Resultados Aceitaram participar 144 dos 193 profissionais dos oito serviços públicos de assistência em saúde mental e psiquiatria. Observou-se que as práticas são baseadas principalmente nos atendimentos individuais, com ênfase nos cuidados de enfermagem, médico e psicológico. As atividades grupais são mais freqüentes nos serviços comunitários. Há pouca prescrição e pouca valorização de atividades de observação, registro e interação terapêutica.
Conclusão Conclui-se que os serviços estão se estruturando, porém, os profissionais ainda encontram dificuldades na implementação das atuais políticas.
Palavras chave: Serviços de saúde mental, recursos humanos, relações enfermeiro-paciente, assistência médica (fonte: DeCS, BIREME).
Psychiatric care in Brazil and throughout the world has been undergoing some significant changes over the last 60 years, the hospital notably becoming replaced as the only healthcare alternative for people suffering from severe and long-term psychiatric disorders by a mental health/disease community-based service network. Such new approach to human resources and services has had an impact on the actions of practitioners from the entire healthcare service network (1-6).
Psychiatric reform in Brazil presupposes services becoming integrated into a single, multi-professional team-based health system; however, the institutions are still being defined and their practice is still in conflict (7-11).
The above represents a tense context, marked by discursive formation in which a new concept regarding how to act (based on the transdisciplinarity of knowledge and the reorganization of work) conflicts with old practices and skills (12-13).
A project was thus initiated for investigating the role and the profile of mental health professionals in central American and Caribbean countries due to concern regarding contextualizing the current overview of such care system, and through the WHO/PAHO Collaborating Centres for Nursing and Mental Health (14-15). Extending this project to Latin-American countries, the Ribeirão Preto-USP Nursing School (a WHO collaborating centre for research into nursing in Brazil) has carried out a similar study in Ribeirão Preto and other Brazilian cities (16-17).
The present study forms part of the aforementioned project and was aimed at characterizing and discussing current practice engaged in by psychiatrists and mental health practitioners involved in Ribeirão Preto's hospital and community services.
This was an exploratory and descriptive study regarding Ribeirão Preto/SP's eight mental health services:
a. Hospital psychiatric services:
1. Hospitalization (in -patient service- Ribeirão Preto/USP medical school) has23 beds;
2. Emergency service (Ribeirão Preto/USP medical school's emergency service - UEHC) unit has six beds for short-term hospitalization; and
3. Psychiatric hospital (Hospital Santa Teresa - HST) has60 beds for treating severe psychiatric cases and alcohol and drug users. Assisted houses and intermediate units are provided for residents' reintegration into society.
b. Extra-hospital care services:
4. Day hospital (Ribeirão Preto/USP medical school's day-care hospital - HDHC) for patients over 15 years old having many diagnoses;
5. CAPSII (psychosocial care-CAPS) reaches 120,000 inhabitants, promoting the psychosocial recovery, reintegration and rehabilitation of patients following their hospitalization;
6. Out-patient care (regional mental health out-patient care -ASM) covers 51% of Ribeirão Preto's population and all patients from the regional area (DRS-XIII);
7. CAPSad (psychosocial care for alcohol and drugs abuse patients -CAPS ad) offers intensive and non-intensive care for patients having psychiatric co morbidities; and
8. Mental Health Centre (one of the city's basic services-NSM) for patients living in the western area of Ribeirão Preto.
Population and sample
All 193highly-qualified practitioners who worked in Ribeirão Preto's mental health and psychiatric services were invited to participate in the study; 144 (74.6%) accepted and signed the informed consent form.
The project was approved by the Ribeirão Preto/USP medical school's ethics committee (13282/2005) and authorized by the city healthcare services.
A questionnaire(based on the original project proposed by the PAHO collaborating centre) was adapted for use in Brazil (16) resulting in a semi-structured questionnaire requesting data concerning identification, sociodemographic information, academic level, base salary and working hours, type of work, praxis and length of time worked in the unit and in the teams, as well as posing questions about mental health policy and its repercussions.
Subjects who had agreed to participate filled in the first two sections of the questionnaire in the presence of a researcher and orally answered the open questions after the study instructions had been explained to them.
STATA was used for analyzing the data base: characterizing the mental health service teams (16-17) and therapeutic action taken by mental health services (the present text).
The present study involved interviewing 144 highly qualified mental health practitioners from eight public psychiatric and mental healthcare services: five of them being community services and out-patient care and three emergency services (including severe cases requiring psychiatric hospitalization).
Table 1 gives the distribution of these practitioners regarding their work location and the type of individual care provided (no statistically significant correlation was found regarding such distribution).
Table 2 shows the distribution of professionals' prescription frequency and type regarding patients suffering mental disorders in the different services; medical and nursing prescriptions prevailed (p<0.01). Around 17 % of the professionals made no prescriptions and 33 % did not answer this question.
Therapeutic group activities involving patients had a statistically significant correlation with health service provision (p<0.01), indicating that most professionals offered this kind of care, mainly at the psychosocial care centre (CAPS) and day-care hospital.
Professionals were involved in group activities provided by three of the community services studied here; practitioners were not involved in activities provided by services involving acutely ill patients (emergency unit, psychiatric hospital and psychiatric hospitalisation unit).
Table 3 shows healthcare frequency (traditionally the nursing team's responsibility, i.e. medication, physical care, comfort care, vital signs and sleep care) involving practitioners in Ribeirão Preto's mental health services.
Since all subjects answered the questions in Table 3 referring to the type of care most directly connected to the activity involving nurses and their team of assistants, a high frequency of negative answers was observed.
Negative answer frequency was still high regarding being involved in recreation, observing behavior, recording activities and therapeutic interaction, even though these were not specific nursing team activities and, therefore, usually carried out by other types of healthcare practitioners.
One hundred and forty-four of the highly-qualified 193 practitioners in Ribeirão Preto's 8 services (76 %) participated in the study. Study compliance varied, even though such compliance reached 100 % at the day-care hospital, the CAPS ad centre (drugs and alcohol abuse care) and the mental health centre. Compliance was low (31 %) at the mental health out-patient centre and reached 73 % at the psychiatric hospital. It should be noted that there were additional health care professionals at the psychiatric hospital, including a biomedical professional, a dentist, a radiologist and a nutritionist (17).
It was observed that individual care was centered on nurses, doctors and psychologists. The nursing team had expressive participation in individual care due to the direct contact offered in the nursing wards, at the emergency unit and at the CAPS psychosocial care centre. Individual care at the out-patient centre focused on medical and psychological care. Activity concentrated on medical care at the mental health centre and the out-patient care centre. Social services and other practitioners had greater presence regarding individual care at the psychiatric hospital.
This scenario reflected the transformation taking place in mental health and psychiatric praxis. Care provided for the mentally ill (who in the past would have been solely dependent on medical and nursing care) today has different distribution regarding team composition and activities provided by professionals within the different psychiatric and mental healthcare services.
The group of practitioners was relatively young, especially the doctors (61 % were under 29 years old);most subjects had graduated 10 to 19 years beforehand (i.e. before answering the questionnaire). Most had received a specialized education and many performed their activities in more than one institution, particularly the doctors; conversely, the nurses tended to work at only one place (according to this sample's profile from the study data) (17).
This was a positive finding as teams consisted of young professionals experiencing the transformation of mental healthcare in Brazil, as well as their inclusion in networks and a concern for the comprehensiveness of healthcare and mental patients' insertion into society, breaking down prejudices and the stigma associated with mental illness. Moreover, these practitioners showed concern for receiving specialized education and keeping abreast of new knowledge, thereby promoting the quality of care. However, a double shift was evident as the subjects were not always involved in the same specialty area and modality, as they searched for better financial and working conditions (17).
Concern has intensified regarding human resources in the area of mental healthcare, both within political arenas (initiatives being provided for assessing existing and necessary resources) and support for practitioners performing their duties and educating new professionals (9,16-17).
Brazilian humanisation policy since 2003 has insisted on the routine of care and management practice; a committee was instituted in 2003 to examine the qualitative and quantitative needs of human resources regarding mental health services, according to the Mental Health Coordination Department management report (2003 to 2006) (6).
Practitioners were to become responsible for overall care, assessing the condition and emotional and behavioral manifestations of the mental patients in their care, both in hospitals and open services. Nevertheless, it was found that 16.7 % of the practitioners were not providing any type of prescription; this, added to the 20 % who refused to answer this question, accounted for 36 % of the professionals who did not prescribe anything. This begs the following questions: "How is mental patients' bio-psycho-social needs being assessed by the different health services? What is each professional's contribution to constructing therapeutic projects designed for psychiatric and mental healthcare patients? Is professional contribution systematized? What is each professional's specific contribution towards preparing projects for promoting mental patients' bio-psycho-social autonomy and social integration within basic and specialized healthcare services?
The results of this study, as well as others related to this theme, showed that even though there has been an improvement in service structure and team composition (as recommended by the Brazilian Ministry of Health), the professionals are still learning to live with t mental disease/health seen from such new perspectives. Studies have shown that there is still a high re-hospitalization index with little coordination of professionals from the teams within families and within other programmes in society, although the 4th Brazilian Mental Health Conference held in 2010 shed light on such matters (6-8,11,17-19).
Information from subjects regarding group activities revealed differences amongst the services studied here; in other words, almost half of the subjects in this study stated that they did not participate in any group therapeutic activity.
Less participation by professionals in therapeutic group activities was observed at two hospitalization units; however, there was higher investment in medical, nursing and psychological care in these services' individual care activities. This result was coherent because it would have been expected that open services' care was not focused on "getting out" but on monitoring by the professional team and their therapeutic goals would have included socio-cultural activities, learning new social roles and (less frequently) medication monitoring and nursing care which is more usual in a hospital setting.
This situation will become changed as the citizen/society relationship becomes transformed, as health/disease becomes the first purpose for action, based on human beings community-based life becoming transformed to meet their needs (4). When people can become the centre for our actions, then human needs and feelings may become satisfied; both converge in attributing value to human beings and, when human needs are satisfied, then this provides the reason for existence and producing action (20). The therapeutic relationship thus promotes growth, development, maturity and personal balance.
More differences were found between professionals and services' activities when analyzing the healthcare results, leading to the question, "If all subjects answered all the questions on the questionnaire and only 22 % of them were nurses, how could 80 % of the total administer mental healthcare out-patient medication? Considering that doctors prescribe and nurses administer medication, who else would be performing the nurses' functions? Giving medication was restricted to nurses at the mental health centre and in most services in this sample. Administering medication for these teams represented a third of the workload regarding in the professionals' actions. Is taking vital signs still an activity restricted to doctors or nurses and their assistants?
It was also observed that physical contact, sleep and comfort were procedures having secondary importance regarding activities engaged in by the professionals in the eight psychiatric care services' teams. Observing and recording information regarding nutrition, sleep, medication, vital signs, weight, physical exercise and sexual interest were indicators of the condition of the disease and the people's reaction to a medication being prescribed.
The results were significant when analyzing the negative side, i.e. more importance should be given to these indicators in both the hospital and community services, especially when the team proposed facilitating each therapeutic project.
A study has shown that inserting nurses into interdisciplinary work, essentially taking over the clinical care of the mentally ill, assists the moon their journey and in constructing bonds within and to the prescribed treatment. However, heterogeneity was frequently observed in new mental health service structure and organization (21-22).
The lack of professionals' focusing on activities such as observing the behavior of the mentally ill, recording their actions and the lack of value given to therapeutic activities should also be mentioned, as this would certainly be reflected in difficulties when preparing singular therapeutic projects.
A lack of understanding was observed regarding the term "therapeutic interaction" since most professionals recognised that they did not interact therapeutically with their patients. The question may have been wrongly wordedor misunderstood; otherwise, what would the professionals in these services be doing if not therapeutically relating to mental patients?
One of the main challenges for consolidating psychiatric reform concerns how practitioners are evaluated for overcoming the paradigm regarding guardianship of the insane; professionals' technical and theoretical qualifications must be considered (3,6,11).
The data showed that transformation is taking place. Differences were revealed concerning the teams' composition and similarities and differences between practitioners' performance in the psychiatric and community mental health services. The psychiatric and mental health services are being structured; however, the practitioners still have difficulties regarding implementing current policy.
Acknowledgements: We would like to acknowledge the financing provided by CAPES/PRODOC grant 0126/05-5 and thank the professionals and mental health institutions who participated in this study.
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